The relationship between ambient particulate matter and respiratory mortality: a multi-city study in Italy.

The association of air pollutants with natural and respiratory mortality has been consistently reported. However, several aspects of the relationship between particulate matter with a 50% cut-off aerodynamic diameter of 10 µm (PM(10)) and respiratory mortality require further investigation. The aim of the present study was to assess the PM(10)-respiratory mortality association in Italy and examine potentially susceptible groups. All deaths from natural (n=276,205) and respiratory (n=19,629) causes among subjects aged ≥ 35 yrs in 10 northern, central and southern Italian cities in 2001-2005 were included in the study. Pollution data for PM(10), nitrogen dioxide and ozone were also obtained. A time-stratified case-crossover analysis was carried out. Different cumulative lags were selected to analyse immediate, delayed, prolonged and best-time effects of air pollution. The shape of the exposure-response curve was analysed. Age, sex, chronic conditions and death site were investigated as potential effect modifiers. We found a 2.29% (95% CI 1.03-3.58%) increase in respiratory mortality at 0-3 days lag. The increase in respiratory mortality was higher in summer (7.57%). The exposure-response curve had a linear shape without any threshold. Sex and chronic diseases modified the relationship between particular matter (PM) and respiratory mortality. The effect of PM on respiratory mortality was stronger and more persistent than that on natural mortality. Females and chronic disease sufferers were more likely to die of a respiratory disease caused by air pollution than males and healthy people.

[Environmental pollution and short-term effects on human health in industrialized urban areas]. / Inquinamento ambientale ed effetti a breve termine sulla salute umana in aree urbane industrializzate.

Several studies investigating the adverse short-term effects of air pollution indicate that even concentrations of air pollutants close to or lower than air quality standards could negatively affect respiratory and cardiovascular health. Therefore, it seems crucial to develop knowledge about health adverse effects in industrialized urban areas. A time-series study on the association between air pollution levels and daily mortality and hospital admissions for respiratory and cardiovascular diseases is currently carried out in the town of Taranto, "area at high environmental risk" according to WHO because of the presence of several heavy industries and elevated rates for all-causes and all cancer mortality, higher than regional mortality rates, especially for lung cancer.

Air pollution and cause-specific mortality in Milan, Italy, 1980-1989.

In several studies, investigators have reported associations among air pollution, weather, and daily deaths, usually from all causes. In the current study, we focused on the difference in lag time between exposure to total suspended particulates or extreme weather and cause-specific mortality in an effort to understand the potential underlying mechanism. We used a robust Poisson regression in a generalized additive model to investigate the association between air pollution and daily mortality. We used a loess smooth function to model season, weather, and humidity; indicator variables for hot days were also used. To examine the relationship in a currently meaningful range, we excluded all days with a total suspended particulate concentration higher than 200 microg/m3. We found a significant association on the concurrent day, both for respiratory infection deaths (11% increase/100 microg/m3 increase in total suspended particulate; 95% confidence interval = 5, 17) and for heart-failure deaths (7% increase; 95% confidence interval = 3, 11). The associations with myocardial infarction (i.e., 10% increase; 95% confidence interval = 3, 18) and chronic obstructive pulmonary disease (12% increase, 95% confidence interval = 6, 17) were found for the means of 3 and 4 d prior to death. We observed an effect of cold weather at lag 1 for respiratory infections and an effect of hot weather at lag 0 for heart failure and myocardial infarctions. The association for all causes and cause-specific deaths was almost identical to that noted previously in Philadelphia, Pennsylvania. Smoothed functions of total suspended particulates suggested a higher slope at lower concentrations, and this finding may account for differences noted between European and U.S. studies. Given that both the dependence between weather and daily mortality and the lag between exposure and death varies by cause of death, analyses by specific causes of death would be very useful in the future.

[Air pollution and daily mortality in Turin, 1991-1996]. / Inquinamento atmosferico e mortalità giornaliera a Torino, 1991-1996.

A time series study was carried out to assess the relationship between the air pollutants measured by the air quality monitoring network and daily mortality in Turin, Italy. We used TSP, SO2, NO2, O3, and CO concentrations measured from 1-1-1991 to 31-12-1996 at three stations of the city network, chosen to represent different, typical circumstances of exposure to air pollution in the town. The analysis was performed by robust Poisson regression model including loss smoothing functions to allow for long-time trend, seasons, temperature and relative humidity. Dummy variables for the days of the week and holidays were also included. The relative risk of death for a unit increase in the pollutant concentration either during the same day (lag 0) in the previous ones (lag up to 5) was computed. The unit increase was 50 micrograms/m3 for TSP, SO2, NO2, O3, and 2 mg/m3 for CO. The average daily number of deaths for natural causes was 21. The relative risks for total mortality were 1.04 for TSP (lag 1), 1.10 for SO2 (lag 2), 1.06 for NO2 (lag 1), 1.01 for O3 (lag 0), 1.03 for CO (lag 1). The relative risks were 1.05 for TSP (lag 0), 1.12 for SO2 (lag 2), 1.07 for NO2 (lag 1), 1.03 for O3 (lag 0), 1.03 for CO (lag 1) for cardiovascular mortality, and 1.08 for TSP (lag 2), 1.20 for SO2 (lag 2), 1.12 for NO2 (lag 2), 1.03 for O3 (lag 2), 1.05 for CO (lag 2) for respiratory mortality.

[Short-term effects of exposure to urban air pollution on human health in Europe. The APHEA Projects (Air Pollution and Health: a European Approach]. / Effetti a breve termine prodotti dalla esposizione ad inquinamento atmosferico urbano sulla salute umana in Europa. I Progetti APHEA (Air Pollution and Health: a European Approach).

During the '80s, evidence was collected that air pollutants concentrations close to, or lower than, air quality standards could negatively influence public health at short term, i.e. within a few days. The European Union financed, between 1993 and 1995, the study "Short term effects of Air Pollution on Health: a European Approach using epidemiological time-series data" (APHEA-1 project), involving more than 25 millions inhabitants in 15 cities, investigated between 1977 and 1991. In this paper, the main results, already published in various scientific journals, are reported. The health effects were studied as mortality for natural causes, cardiovascular and respiratory diseases, and as emergency hospital admissions for all respiratory diseases, bronchial asthma, and chronic obstructive pulmonary disease (COPD). The pollutants whose measures were available for the analysis are sulphur dioxide (SO2), nitrogen dioxide (NO2), particulate matter (PM) measured either as black smoke or total suspended particulate, and ozone (O3). The analysis was carried out by each participating group following a detailed protocol, defined during various workshops, through the construction of Poisson regression models, adjusted for autocorrelation and overdispersion, accounting for variables influencing the daily count of deaths, such as long time trends, season, temperature, day of the week. This paper reports the results of the meta-analysis, performed using the values of each city, as relative risk of dying or being admitted to hospital associated with increases of 50 micrograms/m3 in the 24 hours average concentrations of each pollutant. The daily number of natural deaths was associated with increases in the levels of PM, SO2, O3, and NO2. Cardiovascular and respiratory deaths were associated with increases of the levels of PM, SO2, and O3; cardiovascular deaths were associated also with increases of NO2 concentrations. Emergency hospital admissions for the whole group of respiratory disorders are less consistently associated with PM, SO2, and NO2, whereas there is evidence of association with O3. COPD admissions are related to the air pollutant levels, especially those of O3. Lastly, NO2 levels may play a role in exhacerbating asthma, and SO2 levels can have an effect on asthma in children. A second study is currently going on, involving over 40 millions residents in 34 cities. The aims of this project are: to evaluate the dose-response relationship, to investigate on synergy among pollutants, on the "harvesting" phenomenon, on the geographical differences inside Europe and with the U.S. through the collaboration with a similar American study now in progress. The existence of an association between daily variations in the levels of urban air pollution and adverse health effects was confirmed in Europe. This association is weak, but it involves the whole resident population, so it is a major cause of concern from the public health point of view.

Short-term effects of air pollution on hospital admissions of respiratory diseases in Europe: a quantitative summary of APHEA study results. Air Pollution and Health: a European Approach.

The Air Pollution and Health: a European Approach (APHEA) project is a coordinated study of the short-term effects of air pollution on mortality and hospital admissions. Five West European cities (i.e., London, Amsterdam, Rotterdam, Paris, Milano) contributed several years of hospital admissions data for all respiratory causes. In the current study, the authors describe the results obtained from the quantitative pooling (meta-analysis) of local analyses. The diagnostic group was defined by ICD 460-519. The age groups studied were 15-64 y (i.e., adults) and 65+ y (elderly). The air pollutants studied were sulfur dioxide; particles (i.e., Black Smoke or total suspended particles); ozone; and nitrogen dioxide. The pollutants were obtained from existing fixed-site monitors in a standardized manner. We used Poisson models and standardized confounder models to examine the associations between daily hospital admissions and air pollution. We conducted quantitative pooling by calculating the weighted means of local regression coefficients. We used a fixed-effects model when no heterogeneity could be detected; otherwise, we used a random-effects model. When possible, the authors investigated the factors correlated with heterogeneity. The most consistent and strong finding was a significant increase of daily admissions for respiratory diseases (adults and elderly) with elevated levels of ozone. This finding was stronger in the elderly, had a rather immediate effect (same or next day), and was homogeneous over cities. The elderly were affected more during the warm season. The Sulfur dioxide daily mean was available in all cities, and it was not associated consistently with an adverse effect. Effects were present in areas in which more than one station was used in the assessment of daily exposure. Some significant associations were observed, although no conclusion that related to an overall particle effect could be drawn. The effect of Black Smoke was significantly stronger with high nitrogen dioxide levels on the same day, but nitrogen dioxide itself was not associated with admissions. The ozone results were in good agreement with the results of similar U.S. studies. The coherence of the results of this study and other results gained under different conditions strengthens the argument for causality.

Short term effects of urban air pollution on respiratory health in Milan, Italy, 1980-89.

STUDY OBJECTIVE: To investigate the association between daily urban air pollution and acute effects on respiratory health. STUDY DESIGN: Time series analysis following the procedure defined in the APHEA protocol. SETTING: City of Milan, Italy, from 1980-89. Two air pollutants, total suspended particulates (TSP) and sulphur dioxide (SO2), and two health outcomes, deaths and hospital admissions were considered. The last was analysed according to two age groups. SUBJECTS: Daily deaths and general hospital admissions for respiratory causes in residents who died in Milan or were admitted to local hospitals in that city. MAIN RESULTS: There was an increased risk of respiratory death and of hospital admission associated with increased concentrations of SO2 and TSP. The relative risks were similar for both pollutants, and were higher for respiratory deaths than for hospital admissions. No changes in relation to season were seen in the SO2 effect on respiratory deaths, but there was a suggestion of a higher effect on hospital admissions in the cool months. The seasonal pattern of the TSP effect was inconsistent: for mortality it was higher in the warm period while for hospital admissions it seemed to be higher in the cool months. This last result might be due to chance, although some role could have been played by the hospital admission data on all general admissions for respiratory causes (ICD-9: 460-519) as these are a much less specific end point. CONCLUSION: In Milan, a positive association was found between the daily SO2 or TSP concentrations and the number of deaths or hospital admissions for respiratory causes. This confirms results from other European and North American cities.

[Analysis of mortality by civil status. Tumors of the digestive system]. / Analisi della mortalità per stato civile. Tumori dell'apparato digerente.

Mortality data for the years 1981-1984 have been analyzed by marital status, sex and residence area. Results show high levels of mortality in widowers and widows, especially in areas with high mortality risks. In stomach cancer the widowers/widows mortality excess, compared to married and unmarried, is constant all over the country and does not change in the areas with high levels of mortality. Also for liver cancer mortality the widows show, everywhere, a constant excess compared to unmarried women. Widowers and unmarried men, if resident in north-west, show similar rates; while mortality levels for unmarried men approach those of married ones as the latitude of residence areas decreases and in the south they are equal. Mortality by ages confirms differences by marital status and shows, for many sites, larger variation in the age classes younger than 65-69 years.

[Analysis of mortality by population groups migrating within the country. Tumors of the digestive system]. / Analisi della mortalità per gruppi di popolazione migrati all'interno del paese. Tumori dell'apparato digerente.

This paper analyzes mortality of digestive system cancers in Italy during the years 1981-84 by groups of people migrated inside the country. Individuals born and died in the same region are defined as "stables". "Migrants" indicate individuals for which the region of birth differ from that of residence. Mortality for cancers of oral cavity and pharynx, and of the oesophagus, shows a negative effect of being born in the high risk regions of the north-east and a protective effect of being born in the low mortality regions of the south. Leaving high risk areas brings a positive effect, while to settle there makes mortality getting worse. For stomach cancer, the birth effect is very strong: in this first generation of migrants mortality rates are very similar to those of the stable in the birth areas. A strong migration effect is observed for colorectal cancer mortality: age specific mortality rates in migrants fit well those of host stable population. Liver cancer mortality of migrants from high risk areas approaches the one of the host population. Pancreatic cancer mortality shows a protective effect of being born in the south and a negative effect of residing in the northern high mortality areas.

Short-term effects of air pollution on health: a European approach using epidemiological time-series data. The APHEA project: background, objectives, design.

Recent studies investigating the adverse health effects of air pollution indicate that effects exist around and below the current national and international air quality guidelines and standards. However, the difficult methodological issues involved, and the diversity of analytical techniques so far applied, hinder direct between-study comparability and the drawing of clear conclusions. The APHEA (Air Pollution on Health: European Approach) project is an attempt to provide quantitative estimates of the short-term health effects of air pollution, using an extensive data base from 10 different European countries, which represent various social, environmental and air pollution situations. Within the framework of the project, the methodology of analysing epidemiological time series data, as well as that of performing meta-analysis, are further developed and standardized. Data have been collected from 15 European cities with a total population exceeding 25 million. The exposure data consist of daily measurements of black smoke, sulphur dioxide, suspended particles, nitrogen dioxide and ozone (each available in several, though not all, cities) from already existing monitoring networks. There is substantial variability in air pollution mixtures and air pollutant levels in participating cities. The mean (24 h) levels of SO2 range 27-327 micrograms.m-3 in the winter season, and those of black smoke range 15-292 micrograms.m-3. The mean (1 h) levels of ozone in the summer season range 32-166 micrograms.m-3. The outcome data are daily counts of total and cause-specific deaths and hospital emergency admissions. Data on potential confounders (mainly meteorological and chronological variables) are also used. There is large diversity in the climatic conditions in the different cities.(ABSTRACT TRUNCATED AT 250 WORDS)

[Air pollution and daily mortality among Milan residents, 1980-89. Preliminary results]. / Inquinamento atmosferico e mortalità giornaliera nei residenti a Milano, 1980-89. Risultati preliminari.

Short term effects of air pollutant levels on daily mortality were studied, using time series approach, in Milan from the year 1980 to 1989. The Poisson regression with autocorrelated residuals was applied. This paper reports preliminary results of the analyses on the association between total daily number of deaths and the 24h mean concentrations, on the same day, for two air pollutants: sulphur dioxide and total suspended particulate. A positive and curvilinear relation (with a logarithmic shape) has been found between total daily mortality and concentration levels for each pollutant. This result confirm a steeper increase in mortality at low concentrations, lower than the international standards in use at the moment.

[Analysis of mortality in relation to various demographic phenomena: migration and marital status]. / Analisi della mortalità in relazione ad alcuni fenomeni demografici: migrazioni e stato civile.

This paper analyzes the mortality of major respiratory cancers, certified in Italy in the years 1981-84, by two demographic phenomena: migration and civil status. Direct standardized rates were computed using the total population as reference; a partial analysis of mortality by all causes was also performed. Because of the industrial development in some areas of Italy, great migrations took place in the past within the country, with specific and well known geographic and time patterns. This paper mainly considers migrations towards the industrialized regions of the north-west both from the north-east, occurring between the two world wars, and from the south regions, occurring from the fifties to the seventies. Various studies have shown that cancer mortality decreases with the geographic latitude of the area studied, and that there is a protective effect associated with being born in the southern part of the country. Italian regions were grouped into five areas: north-west, north-east, north-central, south-central and south. Individuals born in the same area of the last residence were defined as "stable", while "migrant" indicates that the area of birth differed from the last residence; for "internal migrant" both regions of birth and last residence are in the same area. For migrants to the north-west, rates by age are reported. For larynx cancer, only mortality of males is discussed. Our study's results confirm that lung cancer mortality is always higher for migrants than it is for stables from the same birth area. Immigrants also show higher rates of lung cancer mortality than the stables in the host areas. The rate ratio of emigrants versus stables in the birth area increases towards the south. The increasing protective role of birth area with decreasing latitude is confirmed for both stables and immigrants. Subjects in the north-west who emigrated from the north-east show age-specific mortality rates higher than stables, both in host and birth areas. Immigrants from southern areas show rates equal to the stables of the host area with increasing age. Results for lung cancer mortality suggest that migrants differed from the stables in socio-economic characteristics not only in the birth areas but also in the host regions. For larynx cancer, migrants and stables show similar rates. Mortality rates for internal migrants and stables decrease with latitude; the protective role of birth area in immigrants is less evident.(ABSTRACT TRUNCATED AT 400 WORDS)

Trends surface models applied to the analysis of geographical variations in cancer mortality.

To discuss different trends of the geographical distribution of cancer mortality, progressively more complex surface models were fitted to cancer death certification data in the 95 Italian provinces for the period 1975-77, using trend surface analysis. This method is based on fitting first to sixth order regression equations, where dependent variables are latitude and longitude, and the independent one is the standardized mortality ratio (SMR) for various cancer sites. The procedure was implemented using the SYMAP package and appropriate routines ad hoc developed. General patterns in geography of cancer in Italy were therefore identified (such as the marked North/South gradient in mortality from most sites), thus helping in discerning main underlying pictures and permitting identification of local abnormalities (positive or negative residuals, corresponding to high or low mortality areas), which are often obscured by more general patterns using standard methods of analysis. Results and maps are presented and discussed in detail with reference to total mortality and three major sites (lung and intestines in males and female breast) for which regression surfaces with satisfactory fitting were identified. Some of the positive residuals (i.e. those for lung and breast cancer in women in urban concentrations of Central and Southern Italy) were already known, and explainable in terms of available knowledge of the causes of the neoplasms, chiefly smoking and reproductive habits in the past. Other findings, such as the consistent area of positive residuals in a chiefly rural area around the mouth of the river Po, offer useful suggestions for further aetiological research.

Cancer mortality in migrant populations within Italy.

Italian death certification rates from all causes of death, all diseases of the circulatory system, all neoplasms, and cancers of the upper digestive and respiratory tract, stomach, intestines, lung and breast in middle age (45-64 years) were analyzed according to selected geographic areas of birth and residence at death. For total cancer mortality and most neoplasms considered, the rates in middle age were closer to those of place of birth than to those of area of residence, although this pattern was more evident for some sites (e.g., mouth or pharynx, esophagus, larynx, stomach or bladder) than for others (e.g., intestines or breast). In most cases, migration had an adverse effect on cancer rates, and the lowest mortality was reported among stable populations (i.e., those with the same area of birth and death). These findings are discussed in relation to the major migration fluxes within Italy during the current century. Moreover, these analyses give information on the quality of Italian cancer death certification, since the observation that area of birth is often a more important determinant of cancer rates than area of residence provides indirect evidence that cancer death certification in various Italian geographic areas is satisfactorily reliable and consistent.

Descriptive epidemiology of intestinal cancer in Italy.

Trends in the death rates from cancers of the intestine (including colon and rectum) in Italy from 1956 to 1981 were analyzed with a standard cross-sectional approach and a log-linear age/period/cohort model. In both sexes there were steady increases in mortality rates between the middle 1950s and the middle 1970s, chiefly explainable in terms of cohort effects. This was followed by a leveling off and stabilization, starting from the younger age groups and more evident in women. The analyses of the geographic distribution of intestinal cancer mortality in the 95 Italian provinces during 1975 to 1977 showed higher rates in the north of the country and in large urban concentrations, and a bimodal distribution of mortality rates, whose minimum corresponded to a distinct north/south separation. Trend surface models fitted to intestinal cancer standardized mortality ratios showed a high determination coefficient even for the simplest models. Residuals, corresponding to outliers, were scattered in a few northern and central areas. In addition, mortality rates for cancers of the intestine in middle age people were considered according to geographic area of birth and residence at death. In both sexes rates of migrant populations were influenced both by area of birth and residence, and, in particular, there was a wide-spread unfavorable effect of residence on migrants from the South to the North (the major migrant flux in Italy). The temporal and geographic variations in intestinal cancer rates observed in this study indicate that Italy may well be a particularly interesting situation for etiologic investigations of colorectal cancers.

A cohort study on vinyl chloride manufacturers in Italy: study design and preliminary results.

A cohort mortality study of 5000 vinyl chloride manufacturers is ongoing in 9 Italian plants. They represent the entire workforce of those ever employed in the production of the monomer and its polymerization. The objectives of the study are to investigate the mortality of the exposed population and to clear up the carcinogenic spectrum of vinyl chloride. This article gives the results for 3 out of 9 plants, Rosignano, Ferrara and Ravenna, which represent about 25% of the total cohort. The expected deaths have been calculated using the mortality rates of the Italian population. For the deceased persons information from the death certificates were used in the analysis of mortality; additional clinical and pathological data were collected (best pathological evidence, b.p.e.). In Ferrara a statistically significant excess for all malignant tumors and lung cancer was detected. In Rosignano and Ravenna the number of observed deaths were small and therefore no comments can be made on cancer mortality. The cohort study is ongoing in the 6 remaining cohorts and the future analysis will consider duration and level of exposure and latency.